Coronary circulation

Ischemic Heart Diseases

Anatomic considerations

Normal coronary blood flow

The resting coronary blood flow= 225 ml/min In strenuous exercise = increase three to four folds.

Phasic changes in coronary blood flow

Epicardial Vs. subendocardial blood flow

Control of coronary blood flow

Metabolic regulation

Nervous control

Metabolic regulation
Blood flow through coronary system is regulated almost entirely by local arterial vasodilatation in response to cardiac muscle need for nutrients.
Increase in rate of coronary blood flow

Increased contraction

 Oxygen demand. Vasodilator substances:

Adenosine. Potassium ions. Hydrogen ions. Carbon dioxide. Bradykinin. Prostaglandins.

 Indirect effect: Symp stimulation HR & contractility Rate of metabolism. activity local blood flow regulatory mechanisms blood flow increases.

Ischemic heart disease

Ischemia:
Lack of oxygen due to inadequate perfusion of the myocardium, which causes imbalance between oxygen supply and demand.

Etiology of ischemic heart disease

Coronary atherosclerosis
The most common cause of myocardial ischemia. Epicardial coronary arteries are the major site. Major risk factors: Increase in LDL. Decrease in HDL. Cigarette smoking. Hypertension. DM.

Normal function of vascular endothelium

Loss of these defenses Inappropriate constriction. Luminal clot formation. Abnormal interactions with blood monocytes & platelets.

Local control of vascular tone. Maintenance of an anticoagulant surface. Defense against inflammatory cells.

Acute coronary occlusion

Thrombosis. Embolism. Local spasm: Direct irritation of the smooth muscle. Nervous reflexes.

Location of the obstruction

Influence the quantity of myocardial ischemia. Determines the severity of the clinical manifestations.

Collateral circulation
With sudden occlusion. With gradual developing atherosclerosis.

Effects of ischemia
Disturbances of myocardial functions:
Mechanical function. Biochemical function. Cell membrane function. Electrical function.

Effect of ischemia
1)Mechanical function:
Failure of normal muscle contraction & relaxation. Ischemia of large portions of ventricle : left ventricular failure. Regional disturbances:
Systolic stretch.

Effect of ischemia
2) Biochemical function:
Fatty acid cant be oxidized. Glucose is broken down to lactate. Reduced intracellular PH and ATP stores.

Effect of ischemia
3) Cell membrane function:
Leakage of potassium and uptake of sodium by myocytes.

4) Electrical function:
ECG changes:
Repolarization abnormalities. Transient ST segment depression.

Electrical instability:
Ventricular tachycardia and fibrillation.

Ischemic heart disease

Stable angina (chronic artery disease)

Acute coronary syndrome: Unstable angina. Acute MI.

Stable angina
An effort-related chest discomfort. Characteristics:
Heaviness. Pressure. Squeezing. Smothering. Choking pain.

Stable angina
Causes:
CAD. Other heart diseases:
Aortic valve disease. Hypertrophic cardiomyopathy.

Stable angina
History:
A man > 50 years. A woman > 60 years. Pain with physical & emotional exertion. Last to 5-10 min.

Stable angina
Radiating pain to the left shoulder, both arms, back, interscapular region, root of the neck, jaw and teeth.

Stable angina
physical examination:
Atherosclerotic disease at other sites. Important risk factors:
Hyperlipidemia DM.

Left ventricular dysfunction. Conditions that may exacerbate angina:

Anemia. Thyroid disease.

Stable angina
Laboratory examination:
Urine analysis ( DM and renal disease). Full blood count. Measurements of:
lipids,. Glucose. Createnine. Hematocrite. Thyroid function test.

Stable angina
Other investigations:
Resting ECG: most important baseline investigation. Stress testing.

Stable angina
Other investigations:
Coronary arteriography.

Stable angina
Management:
A careful assessment. Identification and control of aggravating conditions. Identifications of high risk pts. Application of treatment to improve life expectancy.

Stable angina
Drug therapy:
nitrates. -adrenergic blockers. Calcium antagonist. Antiplatelet drugs.

Unstable angina
Angina pectoris that is rapidly worsening. Characteristics:
Occurs at rest, usually lasting >10 min. Sever and of new onset. Crescendo pattern.

Unstable angina
Causes:
Shares common pathophysiological mechanisms with acute MI. Plaque rapture or erosion. Dynamic obstruction ( coronary spasm). Rapidly advancing coronary atherosclerosis.

Unstable angina
History:
History of chronic stable angina. May present as new phenomena. Chest pain ( substernal region, radiating to the neck, left shoulder and left arm).

Unstable angina
Physical examination:
Diaphoresis. Pale cool skin. Sinus tachycardia. 3rd or 4th heart sound.

Biochemical markers:
Troponin I & T. CK.

Unstable angina
ECG changes:
12 lead ECG is mandatory. ST elevation or depression.

Unstable angina
Management:
Urgent admission to hospital. Bed rest. Antiplatelet. -blockers (atenolol). IV or buccal nitrates. Revascularization.

Stable angina

Unstable angina

Fixed stenosis. Demand-led ischemia. Predictable.

Exercise tolerance test.

Dynamic stenosis. Supply-led ischemia. Unpredictable.

Clinical features. ECG changes. Biochemical markers.

Myocardial infarction
Occurs when there are zero flow or so little flow that it cant sustain cardiac muscle function. Occlusive thrombus in a coronary artery.

Myocardial infarction
Clinical features:
Pain (sever, last longer). Breathlessness. Vomiting. Collapse. Syncope.

Myocardial infarction
Investigations:
ECG:
Partial thickness infarctionST/T wave changes. Transmural infarctionST elevation and Q waves.

Biochemical markers. Chest radiography. Cardiac US.

Myocardial infarction
Management:
Immediate access to hospital. High-flow oxygen. ECG monitoring. I.V analgesia and antiemetic. Detect and manage acute complications:
Arrhythmia. Ischemia. Heart failure.

Myocardial infarction
Complications of infarction:
Arrhythmia. Ischemia. Acute circulatory failure. Pericarditis. Embolism.

Myocardial infarction
Causes of death in MI:
Decreased CO. Damming of blood in the pulmonary or systemic veins. Fibrillation. Rupture of the heart.

Surgical treatment of coronary disease

Aortic-coronary bypass surgery. Coronary angioplasty.

Aortic coronary bypass surgery

Coronary angioplasty